Objective: To study the clinical characteristics and diagnosis of rheumatoid arthritis (RA) in the upper cervical spine.
Methods: The clinical data of 71 patients with RA in the upper cervical spine, 18 males and 53 females, aged 46.2 (23-76), with a mean duration of RA of 18.2 years (2 months-47 years) were retrospectively reviewed. Fifty-three patients received glucocorticoid for more than 3 months. In addition to routine examinations, all patients underwent plain X-ray film taking, CT and MRI scanning, and erythrocyte sedimentation rate, rheumatoid factor (RF) and antistreptolysin O testing.
Results: The symptoms of upper cervical spine appeared at 8.3 years (2 months-46 years) after the diagnosis of RA was confirmed. The clinical manifestations of RA in the upper cervical spine were intractable pain in craniocervical junction or radiating pain. Abnormal postures in the neck and Sherp-Purser's sign were positive in some patients. Progressive neurological dysfunction with the involvement of spinal cord, medulla, or some cranial nerves might gradually appear. Irregular destruction of bone with osteoporosis around the lateral and median atlantoaxial joint was a common finding in the X-ray films and CT scans. Instability of the atlantoaxial joint, including anterior atlantoaxial subluxation, posterior atlantoaxial subluxation and anterior-posterior atlantoaxial subluxation were found in 68 cases, while rotation subluxation was presented in 37 cases. Vertical migration of the odontoid was seen in 11 cases. RF was positive in 18 cases. MRI revealed that the cause of spinal cord compression was the bone tissue and soft tissue pannus.
Conclusions: RA in the upper cervical spine is a common situation in the clinical settings. The key point in the diagnosis of this disease is the identification of instability in the atlantoaxial joint and assessment of the spinal neurological deficit. And a careful analysis of the natural history will further help to achieve a better treatment effect.